Quality Improvement in the Management of Neonatal Persistent Pulmonary Hypertension of the Newborn (PPHN) that Reduced the Need for ECMO

Consultant Neonatologists with expertise in Paediatric Cardiology, Birmingham City Hospital, Sandwell & West Birmingham Hospitals NHS Trust, Birmingham, UK

*Corresponding Author: Vikranth Bapu Anna Venugopalan, Consultant Neonatologists with expertise in Paediatric Cardiology, Birmingham City Hospital, Sandwell & West Birmingham Hospitals NHS Trust, Birmingham, UK; Email: [email protected]

Received Date: January 31, 2024

Publication Date: February 28, 2024

Citation: Vikranth Bapu AV, Sivakumar S. (2024). Quality Improvement in the Management of Neonatal Persistent Pulmonary Hypertension of the Newborn (PPHN) that Reduced the Need for ECMO. Neonatal. 4(1):13.

Copyright: Vikranth Bapu AV, et al. © (2024). 

ABSTRACT

Aim: To improve the management of neonatal PPHN to reduce the need for ECMO. Methods: Data of babies from 2009 to 2019 who were managed for Neonatal PPHN were analysed. Data from 2009 to 2014 were initially analysed to give an insight into the management of Neonatal PPHN which led to the understanding of various parameters in management which needed to be improved. This led to the active Quality improvement programme with education of doctors and nurses regarding aggressive management of babies with PPHN and this led to successful reduction of babies needing ECMO. Results: We analysed two epochs (Aug 2009- Jan 2014 and Feb 2014 to Dec 2019). Over a five year period (2009-2014), 17 infants developed severe persistent pulmonary hypertension of the newborn (PPHN) and required extra corporeal membrane oxygenation (ECMO) from our neonatal unit. We have approximately 6000 deliveries every year in our maternity unit. There were 3 babies every year (from 2009 till 2014) who were referred for ECMO. The problem was identified when an audit was performed in 2013 regarding management of babies with PPHN and this led to the quality improvement project. It was felt that an earlier diagnosis of PPHN, with prompt escalation of treatment, as per the PPHN guideline; early intubation and optimising ventilation, adequate oxygenation, early initiation of nitric oxide, early use of inotropes and escalation of inotropic support and close control of metabolic parameters would have prevented some of these infants from deteriorating. We implemented an active educational programme for the junior doctors and nurses combined with changes to the blood gas chart; the oxygenation index (OI) calculation printed clearly on the chart, prompting calculation of OI in these babies. We also did a simulation session for the medical and nursing team to emphasize the management of PPHN. These were actively discussed in the Quality improvement meetings and once the plan was in place, there were education sessions with each new intake of doctors, comprising a session with the middle grade doctors (registrars) and senior house officer teaching programme and opportunistic reinforcement of this message during multidisciplinary discussion of babies who were subsequently managed for PPHN. This led to significant reduction of babies needing ECMO to 2 babies in 5 years (compared to 17 in the initial 5 years). This is under active surveillance and continues to have less number of babies needing ECMO.  Conclusion: With the active involvement of the medical and the nursing team with proactive education regarding the management of PPHN; the referral rates have been successfully decreased from 3/year (2009 to Jan 2014) to one every 18 to 24 months (2014 to 2023). This has led to significant quality improvement in the care of neonates with PPHN and also helped with saving money for the Trust for such expensive, yet effective treatments.